Traditional (non-integrated) cardiac surgery

[ESU_MD]

Seems like all the students are pretty gung-ho about these integrated programs, i can see the appeal.

I wonder if there are any students who ARE NOT interested in these integrated programs and would still prefer the general surgery THEN cardiac training?

I still dont think its that bad, but maybe I am biased.

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[mwsurg]

MS3 here, long time lurker, first time poster, strong interest in CT surgery (though more thoracic than cardiac).
Can one sit for boards for GS after integrated CT training? If not, then I would prefer spending one more year through traiditional track and dual certified in both GS and CT.

 

[JackADeli]

MS3 here, long time lurker, first time poster, strong interest in CT surgery (though more thoracic than cardiac).
Can one sit for boards for GS after integrated CT training? If not, then I would prefer spending one more year through traiditional track and dual certified in both GS and CT.

I will leave the answer to your question to others.

However, I would in general caution that thought process. On paper it seems reasonable. It definately makes sense integarting med-peds by adding one year to combine dual boarding. However, in surgical specialties, my experience of watching med-students and subsequently residents does not seem to hold the same. 5+ years of general surgery wears on an individual in a way nobody can appreciate until they do it. I have seen too many gung-ho folks motivated for some post general surgery fellowship burnt out and/or derailed. Are they happy? Maybe. Would they have become good ped-surgeons/plastic surgeons/vasc surgeons/CV surgeons..... probably. During that five years you can develop far more reasons to "get started with life" then reasons to continue just to start over again in a fellowship. So, integrated programs, IMHO, do two important things:

1. capture the gung-ho and interested early. And in capture, they have no real choice of lateral transfer. They either complete the integrated or start over in another specialty. This is no different in many respects to any of the other surgical specialties, i.e. uro/OB/Gyn/ortho/etc... If you are in OB and decide you wanted to be general surgeon, you start over.
2. Instead of spending five years hating hemorrhoids and stool and trauma, it allows you to focus on the specialty you actually want to practice. You also don't spend 5+ years with te majority of primary attendings encouraging you into other fields. In theory, you will have most of your attendings able to encourage and mentor you through the focus tasked of enterring the specialty.

 

[DrNick Riviera]

So having just matched this year in GS, I'll field a couple of points to ESU's original post...

I was seriously considering applying to the integrated CT programs with GS as well. I did a cardiac sub-I and loved it. But, I also loved my surg Onc HPB sub-I, and I really enjoy transplant. When I realized that I really loved belly cases as well as cardiac, I couldn't bare risking matching into CT and then deciding that I enjoyed other GS cases more. Furthermore, after talking with a cardiac mentor, we looked at the list of current integrated programs, and he felt that there were maybe only one or two programs (I won't belabor which ones) where the volume was high enough that you could come out of the integrated program and feel like you didn't need an extra year of fellowship to increase your experience. This would basically cancel out the argument that the integrated programs save time over traditional 5+3. For these reasons for me, I decided not to submit my app to integrated programs (I actually had appropriate LORs, CV, personal statement, etc for both GS and CT).

Looking back now after all the GS interviews, etc, I have further insight. I met several folks applying to the integrated programs, and they were totally gung-ho about CT and would never want to do anything else. I on the other hand just know that I enjoyed all specialties off of GS. importantly, though, it is hard to know where CT is going in 7 years. There are plenty of posts about where the future of CT is (ie, more intervention, valves vs CABG, MIS off pump cases, etc), so I won't get into that. But, I can imagine how this may make designing an integrated program more difficult. The traditional programs, working on a 2-3 year cycle are more flexible in where they can offer greater focus, but a 7 year integrated program has to project longer term. That, and you don't get the GS boarding opportunity, for what it's worth.

Those were just my thoughts as a matched GS applicant who was considering the integrated CT programs for a time...

 

[ESU_MD]

I like being a general surgeon too....

but sometimes when its another sunday nite inhouse call as a pgy8+ and I am posting on SDN @ midnite I wonder what the hell I have done to myself.

I still think we need some traditional track options for those who develop an interest in cardiac during the latter years of general surgery.

 

[copacetic]

I think traditional tracks will always be around. It makes sense, especially for internationals. In canada, the programs have all been integrated for about a decade or more, but they still have the tradtional fellowship route.

 

[lordman]

I want to ask if there are other programs that would open the integrated program ??
In other words, are there expectations for the coming 2-3 years ??

 

[kocker]

I ended up going the GS route despite a really strong interest in CT. Like the above poster, I just couldn't commit-- I still am fascinated by transplant and hpb/onc and others (I also don't love laparoscopes)

That said, the more I see, the more I realize that what I seem to love about transplant, surg onc, and critical care are all nicely mixed in CT surgery. There is something I love about the belly and its what took me to GS, but I don't know that I see myself being satisfied by any one field other than CT.

Lately I wish more and more that there was an option to go to CT after pgy3. I think that would be the best of both.

 

[LifetimeDoc]

The all-or-nothing commitment required for these integrated programs probably is a disservice to the medical student and to the profession. If you thought you liked your CT rotation during 3rd/4th year, but later find out during your internship/residency that you liked some other specialty or *gasp* general surgery, then you feel stuck and may end up hating your career choice. This is why I think 3 + 3 programs are better for those wanting to specialize, and given the option to do 3 + 2 if you decide later to just do general surgery (if that's even an option now or in the future).

At this point in my career, as a budding young intern-to-be in a short few months, I really don't know if I want to go on for a CT, Trauma/CC, or Transplant fellowship or just be a rural general surgeon. I'd hate to have to make that decision now (or last year, mind you since you need to prepare early) and later regret it. Heck, I was convinced I was going to be an EM physician until my exposure to surgery during 2nd (small exposures) and towards the middle of 3rd year. Really, how much do we really know about these specialties coming from a third year or fourth year MS perspective? I'd say, not much.

 

[JackADeli]

The all-or-nothing commitment required for these integrated programs probably is a disservice to the medical student and to the profession. If you thought you liked your CT rotation during 3rd/4th year, but later find out during your internship/residency that you liked some other specialty or *gasp* general surgery, then you feel stuck and may end up hating your career choice...

Sure, except this forgets the reality of all the other surgical specialties.... i.e. neurosurgery/ENT/ OBGyn/Ortho/Uro.... they are "all-or-nothing commitment". Or, even more shocking and difficult to change, what if you chose FM and realize you love general surgery... Again, another "all-or-nothing commitment" with limited options for changing to your new found love. Honestly, I think the term "integrated" distracts from the reality... these are self contained specialties or will be eventually such as Uro and ortho and Gyn and neuro did.

I have never understood the mentality that presumes a need for in-decision based exit strategies. Everyone harps on the need of a complete general surgery residency "just in case". What about those general surgery residents.... that discover they want an integrated/focus training in CT?

At some point the comforting instituted back-up plan just in case the student/resident changes their mind needs to come to an end. IMHO, we need to spend more time impressing on med-students to do some real research into their career choices.... because they must choose. The amount of knowledge and techniques we must learn for whatever specialty is increasing. There is a break point at which you are effectively wasting half a decade that could be focused in learning the multitude of increased things in each surgical specialty. I don't think we should be limiting or trying to maintain old teaching paradigms to maintain this "just in case" back up plan. The diservice is beating a general surgery resident into submission until they forgot why they entered this residency (i.e. mandatory stepping stone to reach their original intent) for half a decade until they are just so tired the idea of another 2-3 years gives them seizures and they can't remember why they would consider it or what they loved about that "other field".

 

[LifetimeDoc]

Personally, I feel that all surgical specialties should be 3 + 3 (or whatever combination is necessary to fulfill the necessary learning experience). That would bring together much of the overlap in training, and allow people to make more informed choices about their career as well as making more well-rounded surgeons. I don't believe the limited experiences we get as medical students is sufficient to allow us to make informed decisions about each surgical specialty. I'm sure there are those that have wanted to be CT surgeons or vascular surgeons since they were children, but they probably don't know what it's like to actually be on those services for extended periods of time as a resident. Maybe I'm wrong, maybe right, just my opinion.

 

[ESU_MD]

the 3+3 is an interesting perspective and could allow some time for someone to transition into different paths. Not every program can flourish as an integrated shop, but maybe could provide good training to 3+3 or traditional candidates.

The first 2, maybe 3 years in any surgical path is probably identical as far as learning basics/broad exposure. CV/general/ortho whatever is more than just doing cases. anyone can sew and cut with enough repetition. PA's become very technically adept in the cardiac world quickly with mostly on the job training in alot less time.

How can you really measure what a good surgeon is supposed to be able to do and if they are "better" based on the length/style of their training.

 

[JackADeli]

Personally, I feel that all surgical specialties should be 3 + 3 (or whatever combination is necessary to fulfill the necessary learning experience). That would bring together much of the overlap in training, and allow people to make more informed choices about their career as well as making more well-rounded surgeons. I don't believe the limited experiences we get as medical students is sufficient to allow us to make informed decisions about each surgical specialty. I'm sure there are those that have wanted to be CT surgeons or vascular surgeons since they were children, but they probably don't know what it's like to actually be on those services for extended periods of time as a resident. Maybe I'm wrong, maybe right, just my opinion.

I hear you. But, if there is only one thing I have learned in the healthcare industry it is that everyone at all levels is always trying to find an excuse or rationalization for procrastination and delay in making decisions.

So, in 2011 our media oversaturated, high tech adept, brightest minds of the nation need 2-3 years after medical school just to make up their minds and be absolutely sure they know what they want to do.... I am not sure if this is presumably only a need for surgical specialties? Including Ob/Gyn and Optho in that need? Presumably EM/IM/Peds/Psych/Path/etc... do not require additional years of exposure to make their decisions?

Or, maybe it's that the indecisive/unsure med-students in such a luxurious delay of decision system can actually make a definitive decision to do either surgical or non-surgical after their "limited experiences" in med-school. Maybe the answer is not 3yrs of a "general" surgical residency experience for all surgical specialties. Maybe the answer is extend medical school to six years so the unsure/indecisive/modern med-students can get the full flavor accross all specialties.

 

[ESU_MD]

"limited experiences" in med-school. .

probably because alot of students nowadays spend so much time away from their rotations at "lectures" and other mandantory things. couple this with the fact that alot of students dont have to take call or round with the residents on the weekend....

 

[JackADeli]

probably because alot of students nowadays spend so much time away from their rotations at "lectures" and other mandantory things. couple this with the fact that alot of students dont have to take call or round with the residents on the weekend....

I would definately agree the structured components are not necessarily ideal. However, I have worked with numerous students. They are bright and very, very adept at using the structured education plan to assure maximal "good time" on each and every rotation.

Residents that I have seen "drop" from a program often cite not knowing "what it was really about". These are the same individuals that I often met in interview and/or reviewed app personal statements proclaiming how much they loved surgery and how "fun" it was...

The problem is, anyone can structure their learning into the most enjoyable components. I see students routinely decide not to attend a case cause, "I already saw that". While it is important to maximize exposure and experience, I have seen few students volunteer for the dis-impaction or rigid sig for volvulus or the nasty hemorrhoid or etc... Instead, there is an exponential expectation of enjoyment for every minor task completed.

If you want to do any specialty, you need to investigate it and arrange to participate in the worst parts of it and especially get a flavor for the bread & butter. Tell the attendings, "I am really interested in this specialty. I don't want the perfect sales pitch. I want the under-belly experience. On this rotation, I would like to experience the bread and butter and the negatives of this field". This goes for pedes/IM/FMOB/surge/Uro/Ortho/Anesth/Psych/etc. IMHO, there is no one to blame if you are "blindsided" by your residency choice. Use an elective, talk to an attending, do something. Frankly, proclaiming ignorance and mistake in decision should be embarassing.

In the end, wether you choose a career in medicine, lawyer, Vet, engineer, school teacher, etc... you choose and there are consequences seen and unseen to every choice.

 

[dienekes88]

Seems like all the students are pretty gung-ho about these integrated programs, i can see the appeal.

I wonder if there are any students who ARE NOT interested in these integrated programs and would still prefer the general surgery THEN cardiac training?

I still dont think its that bad, but maybe I am biased.

The only fear is that some big programs have integrated already and many are in the pipeline. Will all the big places integrate (to the exclusion of traditional track people) by the time the current generation of medical students is applying for fellowship if they go the GS route? It would suck to be caught out in the transition and stuck without a fellowship. Part of the gung-ho aspect might be the realization that it might not be an option in the future.

Regarding med students going soft... it's a sign of the times: lifestyle is king. That's why in the pre-med forums, everyone's drooling over the number of derm and radonc matches on a given school's match list. A lot of people just don't want to be in the hospital rounding on the weekends and then gathering supplies for chest tubes. These are the same people who shockingly would prefer not to be called in for a double lung transplant on the day they're supposed to be off. Other people like all that stuff!

Once the integrated programs establish themselves, there'll be a cult that grows up around it - just as is the case with neurosurgery. Most of the neurosurgeons I've met spend their time trying to convince medical students that the lifestyle is not as bad as people assume. When people start associating "integrated cardiothoracic" with the phrase "working all the time," the probability of someone wandering into a program and then being surprised will decline. I guess it's just a part of the growing pains that the field will be going through.

 

[LifetimeDoc]

I've never understood this idea that being interested in a field requires that you commit to it sometime during 3rd year or earlier. I wouldn't be surprised if they didn't start requiring students to sign a binding contract to go into a specific specialty before they were allowed to enter medical school!

I didn't decided upon general surgery until early 4th year. I made sure I had maximum exposure to emergency medicine and surgery throughout 3rd year, and think I have made the right decision. But how would I know that I want to be a vascular surgeon and nothing else? Or maybe trauma? I thought I liked trauma, but now I'm more interested in transplant surgery. I'm sure that might change as I enter surgery as a resident. Did I volunteer to be a part of the "under-belly" of surgery, as you termed it? Yes, I volunteered to scrub in on the proctoscope procedures, the nasty hemorrhoids, and even requested the most notoriously hardest team because I wanted to see what it was like? Was I allowed to do procedures like the residents? Absolutely not, the resident needed their procedure numbers and it wasn't the place for the student.

How educational is it to see your 20th laparoscopic cholecystectomy when you're the person holding a retractor at some weird angle with the resident blocking your view of the monitor? Of course the student is going to say "I've seen enough", because they aren't the one being trained or really involved in cases in the OR. /soapbox

Back to the original topic, why are people interested or not in integrated programs? I'd have to say because you have to commit to a narrow speciality before you are even exposed to what is available in surgery. It's easy to say you love vascular (or pick ortho or whatever surgical sub-specialty) as a third year just because you heard something from someone about pay/lifestyle or had an awesome attending, and then find out 3 years in that you really wanted to do general surgery or CT. I just think that you can realize you want to be a surgeon in medical school, but that you really don't know what specialty in surgery is a best fit for you until later, IMHO.

 

[ESU_MD]

I doubt that these integated progras are a total cakewalk, no call, etc... Its quite possible, in fact probable that people will want to change specialties here too.

 

[dienekes88]

I doubt that these integated progras are a total cakewalk, no call, etc... Its quite possible, in fact probable that people will want to change specialties here too.

Not sure who said they would be a cakewalk. I agree that there might be some significant attrition in the early years while the cult of cardiothoracic surgery training is built into the collective medical school brain. That might be part of why doing a sub-I or being well-known to your home program is important to match. They have to do their best to make sure that you're the kind of person who wants to do it, e.g. rounds willingly on the weekend as opposed to the student who longs to be on the other side of the ether drape 'cause he's a little sleepy.

 

[Severus]

That's why in the pre-med forums, everyone's drooling over the number of derm and radonc matches on a given school's match list.

That had me LOLing yesterday. I can just picture their personal statements littered with heartfelt sentiments about "saving the developing world one rash at a time".

 

[SocialistMD]

At some point the comforting instituted back-up plan just in case the student/resident changes their mind needs to come to an end. IMHO, we need to spend more time impressing on med-students to do some real research into their career choices.... because they must choose. The amount of knowledge and techniques we must learn for whatever specialty is increasing. There is a break point at which you are effectively wasting half a decade that could be focused in learning the multitude of increased things in each surgical specialty. I don't think we should be limiting or trying to maintain old teaching paradigms to maintain this "just in case" back up plan. The diservice is beating a general surgery resident into submission until they forgot why they entered this residency (i.e. mandatory stepping stone to reach their original intent) for half a decade until they are just so tired the idea of another 2-3 years gives them seizures and they can't remember why they would consider it or what they loved about that "other field".

The problem with this is that medical students are getting less and less actual exposure to the true life of a general surgery resident. While we want them to decide early, we don't provide them with enough of a base on which to make those decisions. The paths are diverging and the med student is left in the middle, not knowing what is what.

 

[Thanatos]

Seems like all the students are pretty gung-ho about these integrated programs, i can see the appeal.

I wonder if there are any students who ARE NOT interested in these integrated programs and would still prefer the general surgery THEN cardiac training?

I still dont think its that bad, but maybe I am biased.

I'm not a student, but even if I was I think I would still plan on going the traditional route, I like doing general surgery and can't help but think there will be some advantages to having sewn a few more vascular/transplant anastamosis. I'm in a top heavy academic program where the chiefs operate a ton, I think taking on that leadership/decision making role will have some benefit. The chief year looks like one of the better years in some ways, and after shoveling so much **** as a junior I want my time in the sun!

The other thing for those of us already in residency is you can only jump from gen surg to an integrated program at your home institution. At least thats my understanding, correct me if I'm wrong. I like my program and feel like its strong in gen surg and especially trauma, but its not exactly a cardiac powerhouse as we've had a few people leave/retire in the past year. So why would I stay here for CT, even if they had an integrated program, when I could apply to much better programs and probably match with the fellowship being so wide open.

Its hard to imagine all programs will suddenly go integrated overnight and that the traditional model will cease to exist, especially in a field struggling for good candidates. I think they will find a way to take qualified people any way they can.

In a tight job market, will the traditional route give you a competitive edge? Tried and true versus the unknown? I don't know, but I'll try to make a case for it when they ask why they should hire me over someone else.

Finally there is a suspicious, paranoid side of me that will feel better about being board certified in gen surg in case CT really does go to hell.

 

[copacetic]

what are the difference fellowships that can bed one after residency? So far I have heard of:

Pediatric/congenital
Transplant
Robotics
Valve

are there others? for example is there one in electrophysiology (bi-Vs. ICDs and the like), and is there a database that lists where where to find these programs>

 

[ESU_MD]

in my mind....

getting a job from an integrated program may be ok since the faculty there will be very vested in making sure you succeed, willing to help, etc. otherwise they wouldnt have wasted the time and effort to create a NEW training program.

i think the places that have the integrated programs would still attract the best avail candidates for "traditional" too.

at some places, the only thing the staff is interested is in you leaving the area, preferably the region to eliminate competition.

as was said multiple times, in multiple ways on this board... the programs that suck should be shutdown.

 

[Buzz Me]

what are the difference fellowships that can bed one after residency? So far I have heard of:

Pediatric/congenital
Transplant
Robotics
Valve

are there others? for example is there one in electrophysiology (bi-Vs. ICDs and the like), and is there a database that lists where where to find these programs>

There are lots of one-year "clinical" fellowships. VADS, heart failure, endovascular, VATS, minimally invasive esophagectomies, etc.

 

[copacetic]

There are lots of one-year "clinical" fellowships. VADS, heart failure, endovascular, VATS, minimally invasive esophagectomies, etc.

is there like a list somewhere, where all these programs can be found?

 

[ESU_MD]

Almost all of these programs are informal. Someone had a list on thoracic resident website. Tsra.com or something, but it was outofdate. You basically pick what you want, where and for how much you want to suffer

 

[copacetic]

Almost all of these programs are informal. Someone had a list on thoracic resident website. Tsra.com or something, but it was outofdate. You basically pick what you want, where and for how much you want to suffer

....outstanding

 

[Buzz Me]

That had me LOLing yesterday. I can just picture their personal statements littered with heartfelt sentiments about "saving the developing world one rash at a time".

 

[JackADeli]

...fellowships that can be done after residency? ...are there others? for example is there one in electrophysiology (bi-Vs. ICDs and the like)...

I would be surprised to see anyone do a fellowship in pacemakers, defibs, etc... that would be somewhat sad. We did pacers and such in general surgery. The CT fellows were doing complex afib ablation procedures.

On another note, if anyone hasn't looked at the "Amercian College of Surgeons; Surgery News" that just came out, you might want to read article page #9. It is about "Cardiothoracic Workforce Survey Raises Concerns"..... worth thinking about when planning your career.

Go to www.facs.org and click on periodicals, surgery news..... it is March 2011 issue

 

[DO_Surgeon]

I would be surprised to see anyone do a fellowship in pacemakers, defibs, etc... that would be somewhat sad. We did pacers and such in general surgery. The CT fellows were doing complex afib ablation procedures.

On another note, if anyone hasn't looked at the "Amercian College of Surgeons; Surgery News" that just came out, you might want to read article page #9. It is about "Cardiothoracic Workforce Survey Raises Concerns"..... worth thinking about when planning your career.

Go to www.facs.org and click on periodicals, surgery news..... it is March 2011 issue

As someone getting ready to start their fellowship in three months, this stuff scares the **** out of me. I knew all about the job issues long before applying and interviewing for CT surgery but this still worries me. I am hoping this predicted shortage comes true over the next few years. Are most of these fellows IMGs with visa issues or super selective american grads who refuse to live anywhere but the coasts?

 

[SLUser11]

Go to www.facs.org and click on periodicals, surgery news..... it is March 2011 issue

Scary stuff. Well, I guess butts and guts offers more job stability. People will still need their cancers out for a while, but who knows...chemo is getting so good, maybe even colectomies will become rare in the future.

On a side note, that magazine always has a million commercials for the Kumar clamp and the Kumar T anchors (page 8)....I've never used any of those products, and they seem sort of silly. I mean, how hard is it to just pass suture or do a cholangiogram the old-fashioned way? Has anyone used these, and do they have utility for people that are good at laparoscopy?

And a final, more important question: Do you think there is really a jingle for "Fire one, fire two, and you know what to do," or do you think he just put some music notes next to his slogan?

 

[JackADeli]

...On a side note, ...the Kumar clamp ..Has anyone used these, and do they have utility for people that are good at laparoscopy?...

I like the Kumar clamp for cholangios. I've used it alot. Not required but decent enough.

...I am hoping this predicted shortage comes true over the next few years. Are most of these fellows IMGs with visa issues or super selective american grads who refuse to live anywhere but the coasts?

The shortage to my understanding is a 5-10+ year projection. I am not sure one can bet the market correction will be useful to them in 2-3 years.

I don't think this is an issue of visas and IMGs. I have watched US grads from good names really struggle just to get a decent offer in a reasonable place. Keep in mind, an internet search will show plenty of jobs in very low volume regions. It isn't just about living in a big city. Practicing "high-end" in rural settings is akin to not practicing.

The other issue is the combo jobs. Do google search; plenty of jobs... if you want to do cardiac, thor, gen-vascular, and +/- trauma. Fewer jobs if you want just CV or just gen thor. Also, keep in mind that plenty of grads from "big name" are then still doing 1-2 years additional fellowships just to get into a first job in the 250-350k range.... i.e. general surgery pay range.

 

[Black Surgeon]

Are most of these fellows IMGs with visa issues or super selective american grads who refuse to live anywhere but the coasts?

With the reported 38 % with less than 2 interviews, the 17% with no interviews and the 31% with no job offers, I doubt that geographical selectivity is the issue at hand. Especially when considering the 17% reporting having debt "exceeding $200,000".

As many have stated, I personally wouldn't consider the integrated programs unless there was a route for ABS certification in GS.

It is one thing to be in training for 10+ only to be left wanting: A CT trained surgeon working as a GS, and another to be in training for 10+ only to be left hungry: without a job and 200,000 + of loans. My love for CT leads me to view the former as acceptable, but how does anyone reconcile with latter: 10+ years of training only to be greeted with a SUPER SUPER fellow position for 2 to 3 years post training? Yes, the Congenital and maybe the VAD/transplant guys do this by choice and out of necessity, but to be forced into it is a different story.

 

[HNANAL]

yeah whatever, people are always predicting gloom and doom.

 

[JackADeli]

yeah whatever, people are always predicting gloom and doom.

Saying it will get worse is a "prediction". However, the actual numbers are not predictions but rather current day realities.

With the reported 38 % with less than 2 interviews, the 17% with no interviews and the 31% with no job offers...17% reporting having debt "exceeding $200,000"...

What has not been forthcoming for the recent years of grads is any idea how the market will turn around. And, yes, the current studies and indicators have not shown improvement in these numbers...thus the "predictions".

 

[ESU_MD]

30% without jobs probably correlates to the percentage of residents with significant visa, immigration or " other cultural issues"

The glory days are over for sure, but its not the end of theprofession.

If you have to make a choice of going into ctsurg based on statistics, or predictions, then you probably should consider another field.

 

[Black Surgeon]

If you have to make a choice of going into ctsurg based on statistics, or predictions, then you probably should consider another field.

Wow! That's a pretty strong statement, but not too surprising to hear from someone who has crossed that bridge and has a job offer to show for it.

I do know one SUPER SUPER SUPER fellow who was fully trained in CT surgery in his homeland, followed by an ECMO fellowship in England (10+ years). He persisted to relocate to the US to start over with a General surgery residency, redo a CT fellowship and to follow it with a congenital/pediatric fellowship (10+ years) which he completed somewhat recently (a little over two years ago). Now if that isn't love and passion for CT surgery, than I don't know what is. There is one guy here on SDN who is presently training under him, maybe he'll get a hold of this and chime in.

 

[SLUser11]

If you have to make a choice of going into ctsurg based on statistics, or predictions, then you probably should consider another field.

Wow! That's a pretty strong statement, but not too surprising to hear from someone who has crossed that bridge and has a job offer to show for it. .......Now if that isn't love and passion for CT surgery, than I don't know what is.

This is very dramatic, but I'm not sure how practical it is. You have to make a living, after all.

I don't see CT surgery as being much different than other surgical subspecialties, yet it is often romanticized into some noble profession that only a select few bad@#ses have the talent and fortitude to perform.

That being said, I do think it's important to love your work.

 

[Buzz Me]

I don't see CT surgery as being much different than other surgical subspecialties, yet it is often romanticized into some noble profession that only a select few bad@#ses have the talent and fortitude to perform.

Likely for any number of reasons:

(1) The "golden age" of surgery was back in the 1970s and 1980s, and it was dominated by the big money-makers for the hospital: the cardiac surgeons.
(2) You do need great technical skills to be able to sew a distal anastomosis during an off-pump case. Having done that myself, compared to sewing any sort of anastomosis in Vascular (and this includes tiny vessels like the ulnar or dorsalis pedis arteries), or Transplant, or Peds - and even compared to some microsurgical techniques I used while in the lab - I will attest to its difficulty.
(3) Cardiac surgeons tend to have huge egos (perhaps due to the intensity of the work?) and love to proclaim how great they are to the rest of the world.
(4) Bad lifestyle field that tends to attract "martyrs" that are gluttons for self-punishment.

 

[SLUser11]

Likely for any number of reasons:

(1) The "golden age" of surgery was back in the 1970s and 1980s, and it was dominated by the big money-makers for the hospital: the cardiac surgeons.
(2) You do need great technical skills to be able to sew a distal anastomosis during an off-pump case. Having done that myself, compared to sewing any sort of anastomosis in Vascular (and this includes tiny vessels like the ulnar or dorsalis pedis arteries), or Transplant, or Peds - and even compared to some microsurgical techniques I used while in the lab - I will attest to its difficulty.
(3) Cardiac surgeons tend to have huge egos (perhaps due to the intensity of the work?) and love to proclaim how great they are to the rest of the world.
(4) Bad lifestyle field that tends to attract "martyrs" that are gluttons for self-punishment.

Agree with 3 and 4 for sure.

Of course, I have nothing against CT surgery. As a student, it was my greatest interest, and most of my surgical mentors at SLU were CT surgeons.

There are lots of surgeries across multiple subspecialties that are technically difficult. I don't see CT surgery as any more technically demanding....that is of course unless you ask a CT surgeon.

Anyway, I'm probably just being intentionally inflammatory to stir up some discussion since SDN has been so boring for a little while.....

 

[dienekes88]

Agree with 3 and 4 for sure.

Of course, I have nothing against CT surgery. As a student, it was my greatest interest, and most of my surgical mentors at SLU were CT surgeons.

There are lots of surgeries across multiple subspecialties that are technically difficult. I don't see CT surgery as any more technically demanding....that is of course unless you ask a CT surgeon.

Anyway, I'm probably just being intentionally inflammatory to stir up some discussion since SDN has been so boring for a little while.....

One of the congenital heart surgeons here loves to tell people that he could teach a monkey to operate.

Then again, I heard from a trustworthy source that to create the bad@ssness of a LIMA-LAD outside a cardiac room, you would have to have 2 neurosurgeons clip ACOM and MCA aneurysms at the same time in the same patient, and all the Pepsi machines in the hospital would have to magically change into Coke machines. Just sayin'.

Likely for any number of reasons:

(1) The "golden age" of surgery was back in the 1970s and 1980s, and it was dominated by the big money-makers for the hospital: the cardiac surgeons.
(2) You do need great technical skills to be able to sew a distal anastomosis during an off-pump case. Having done that myself, compared to sewing any sort of anastomosis in Vascular (and this includes tiny vessels like the ulnar or dorsalis pedis arteries), or Transplant, or Peds - and even compared to some microsurgical techniques I used while in the lab - I will attest to its difficulty.
(3) Cardiac surgeons tend to have huge egos (perhaps due to the intensity of the work?) and love to proclaim how great they are to the rest of the world.
(4) Bad lifestyle field that tends to attract "martyrs" that are gluttons for self-punishment.

Those 4 could just as easily apply to Neurosurgery. There just aren't as many Neurosurgery worshippers in this forum, because they have their own sub-forum.

 

[JackADeli]

...You do need great technical skills to be able to sew a distal anastomosis during an off-pump case...

...There are lots of surgeries across multiple subspecialties that are technically difficult. I don't see CT surgery as any more technically demanding....that is of course unless you ask a CT surgeon...

One of the congenital heart surgeons here loves to tell people that he could teach a monkey to operate...

I think those replies about sum up my perspective. I have had alot of mentors in general surgery. The best were always the high end surgeons that took the time to demistify the specialty.

You ask Mulholland, he might say being a whipple surgeon is for only the most technically gifted. Yet, I had plenty of great mentors. And after their patiently taking me through a half dozen, they all said I could be a good whipple/pancrease surgeon. You ask some of the big vascular surgeons, they might say being a vascular surgeon is for only the most technically gifted. Yet, I had plenty of great mentors. And after their patiently taking me through a dozens of AAAs & carotids & mesentary bypasses & fem to forevers, they all said I could be a good vascular surgeon. I even rotated on CV/CT in general surgery. I got to throw some proximals. Great mentors. And after their guidance, they all said I could be a good CV/CT surgeon if I so desired.

And, what they all said, "Your fine. not really a protege but that is not what being a good surgeon is about. ANYONE can do this, that, or the other if properly taught and provided enough experience...".

I have no doubt CV surgery requires skill. I also have no doubt that if properly trained and provided with enough actual OPERATIVE OPPORTUNITY most if not all that choose that path will be "good". Then they can go around and buff up the legend and try to claim how technically tough it is.....

 

[ESU_MD]

Are you guys really CT haters?? ....or just jealous? there are plenty of open spots if you want to sign up!

I agree that most surgeons can be taught to do most cases. whipple, avr,cabg, infrarenal AAA, liver resection, etc..

however, i still think that there are cases in CT that are just plain more complex than anything seen in most other specialties. an example would be aortic arch surgery, or even better re-do aortic arch surgery.
I am having a hard time thinking of something that is equally as challenging in general surgery (or other fields) as a circulatory arrest arch case.

I dont think there is anything mystic about it... you just need to know what you are doing and commit enough time to develop your thinking/skills. I think the ctsurg stereotype isnt as prevalant as you think. most guys I know in the field just want to go home at the end of the day, have a drink, etc.. very few are walking around the hospital trying to get people to worship them. unfortunately, those days have been over for ~20yrs.

(wouldnt it suck to have a ct surg sub-forum?)

 

[Black Surgeon]

ANYONE can do this, that, or the other if properly taught and provided enough experience...".

Anyone who aspires to go into CT almost has to believe the statement above, that, or rely on narcissism and think themselves "golden" or naturally gifted.

Nevertheless, I can't help but to be reminded of the newly minted CT guys (trained at top programs) on our service still needing their hand held (through some tough cases) by the seniors 2 to 3 years post training. Is this a norm throughout surgical specialties? or more a testament of the level of technical difficulty in CT?

 

[SLUser11]

Nevertheless, I can't help but to be reminded of the newly minted CT guys (trained at top programs) on our service still needing their hand held (through some tough cases) by the seniors 2 to 3 years post training. Is this a norm throughout surgical specialties? or more a testament of the level of technical difficulty in CT?

Tough to say for sure. However, it could be a testament to the lack of autonomy at some of these programs. It's definitely not the norm.

We have had a couple "newly minted" CT guys come onto staff at KU, and they are usually just fine, without needing much hand-holding. However, I do believe that as a newly minted surgeon in any specialty, it's important to have a senior partner or mentor available for the inevitably difficult situations that could overwhelm you.

 

[Black Surgeon]

Tough to say for sure. However, it could be a testament to the lack of autonomy at some of these programs. It's definitely not the norm.

We have had a couple "newly minted" CT guys come onto staff at KU, and they are usually just fine, without needing much hand-holding. However, I do believe that as a newly minted surgeon in any specialty, it's important to have a senior partner or mentor available for the inevitably difficult situations that could overwhelm you.

I should have been more specific and have stated that most of the post training hand holding I've seen has been on pediatric/congenital CT cases and not in adult CT, this seems to be the norm in this world, or at least at my institution.

 

[JackADeli]

...i still think that there are cases in CT that are just plain more complex than anything seen in most other specialties. an example would be aortic arch surgery, or even better re-do aortic arch surgery.
I am having a hard time thinking of something that is equally as challenging in general surgery (or other fields) as a circulatory arrest arch case...

Agreed. I do not take anything away from the dedication and shear hard work getting from point-A (med-school) to point-B (Renowned attending). But, I have had the fortune during med-school and gen-surge residency to have honest attendings tell me about their first, less then famous 5-10 years. Or, pull aside the scrub nurse with gray hair and hear her tell me about the very long cardiac cases or thoracic cases earlier in the attendings career.

Yes, I have seen newly minted CV surgeons perform fast and good too. But, they have been the ones that point back to their program, excellent mentors, and heavy hands on operative experience.

...I can't help but to be reminded of the newly minted CT guys (trained at top programs) on our service still needing their hand held (through some tough cases) by the seniors 2 to 3 years post training. Is this a norm throughout surgical specialties? or more a testament of the level of technical difficulty in CT?

I think, based on conversations and observation, many "top programs" are not known so much for their "teaching" as much as they are known for their university name, attending name, and prior historical legends.

...it could be a testament to the lack of autonomy at some of these programs...

Bingo! We have a winner.

 

[SouthernSurgeon]

I should have been more specific and have stated that most of the post training hand holding I've seen has been on pediatric/congenital CT cases and not in adult CT, this seems to be the norm in this world, or at least at my institution.

I've seen this type of hand-holding in adult CT as well; IMHO it is almost purely a result of inadequate training rather than a reflection of the difficulty of the field. At my med school there were several attendings who seemed to think autonomy was a four letter word. The senior fellow struggled to put a patient on and off pump independently, and despite being three months from being an attending at the time would likely be unable to do a straightforward CABG on his own. He ended up doing a one year super fellowship to further improve. This was, per the residents, pretty reflective of the typical CT graduate's skill level from that program.

 

[Black Surgeon]

However, it could be a testament to the lack of autonomy at some of these programs. It's definitely not the norm.

Bingo! We have a winner.

I've seen this type of hand-holding in adult CT as well; IMHO it is almost purely a result of inadequate training rather than a reflection of the difficulty of the field. At my med school there were several attendings who seemed to think autonomy was a four letter word. The senior fellow struggled to put a patient on and off pump independently, and despite being three months from being an attending at the time would likely be unable to do a straightforward CABG on his own. He ended up doing a one year super fellowship to further improve. This was, per the residents, pretty reflective of the typical CT graduate's skill level from that program.

Alright, you guys are definitely in agreement, I'll take your word (s) for it.